| NPI | 1124555206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 324113) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS020535) |
| Enumeration Date | 2017-05-19 |
| Last Update Date | 2023-09-21 |